Frequently asked questions about health insurance
coverage options in Texas
Texas utilizes the federally run marketplace (exchange) at HealthCare.gov and has one of the highest exchange enrollments in the country. Only Florida and California have higher exchange enrollment.
The insurance marketplace offers health insurance plans for individuals and families who need to buy their own health insurance. This includes early retirees (who will transition to Medicare when they turn 65), self-employed residents, and people employed by a small business that doesn’t offer employer-sponsored health benefits.
Using the marketplace is optional; individuals and families in Texas can choose instead to buy coverage directly from a health insurance company. But the marketplace is the only place where Texas residents can qualify for financial assistance benefits based on their household income. This includes premium subsidies (which offset the monthly cost of coverage) and cost-sharing reductions (which reduce out-of-pocket medical costs — deductibles, coinsurance, and copays).
Read our overview of the Texas health insurance marketplace – including news updates and exchange history.
In Texas, open enrollment for individual/family health coverage runs from November 1 through January 15. Outside of open enrollment, you’ll need a qualifying event (which triggers a special enrollment period) in order to enroll in coverage or make a change to your plan.
Read more in our comprehensive guides:
For 2022, four insurers joined the Texas marketplace. Plan availability varies from one area to another, but a total of 14 insurers offer 2022 coverage in the Texas marketplace:
- Aetna CVS Health
- Celtic/Ambetter (Ambetter from Superior Health Plan)
- Blue Cross Blue Shield of Texas
- Bright Healthcare
- Friday Health Plan
- Moda Health Plan
- Community Health Choice
- Scott & White Health Plan
- UnitedHealthcare of Texas
And for 2023, Cigna and Ascension Personalized Care are joining the Texas market. 2023 plans will be available for purchase starting November 1, 2022.
The ACA would have expanded Medicaid to cover all legal residents in Texas with incomes up to 138% of the federal poverty level, but a Supreme Court ruling in 2012 allowed states to opt out of Medicaid expansion. Texas remains among the dwindling minority of states that have continued to reject the expansion of Medicaid (as of 2022, there are 12 states that haven’t expanded Medicaid).
Because of the state’s refusal to expand Medicaid, 771,000 Texans are in the coverage gap, with no access to financial assistance with their health insurance. This is far more than any other state that has not expanded Medicaid – the next highest is Florida, with about 415,000 people.
Between 2013 and March 2017, Texas’ existing Medicaid/CHIP program saw an increase of about 13%, despite the very strict eligibility guidelines that the state uses. By 2019, enrollment had actually dropped to below where it had been in 2013.
But by March 2022, total enrollment in Texas Medicaid/CHIP was 27% higher than it had been in 2013. The COVID pandemic has been driving Medicaid enrollment higher across the country, due to the widespread job losses and income reductions. This is true even in states like Texas that have not expanded Medicaid under the ACA. And the Families First Coronavirus Response Act has paused Medicaid eligibility redeterminations nationwide. That continues through the end of the COVID public health emergency. So Medicaid enrollment has continued to increase during the pandemic.
Read more about Medicaid in Texas.
Medicaid eligibility rules in Texas are particularly strict: Non-disabled adults without dependent children are ineligible regardless of income, and parents with dependent children are only eligible if their household income is extremely low ($230 per month or lower, for a single parent with two children).
Texas regulations regarding the definition and duration of short-term health plans align with new federal short-term rules. As a result, short-term health insurance plans in Texas can have initial terms of up to 364 days and can be renewed for a total duration of 36 months.
Read more about short-term health insurance in Texas.
There were more than 4.4 million Texas residents enrolled in Medicare as of April 2022. That’s about 14% of the state’s population, versus 19% of the U.S. population enrolled in Medicare. Most of the state’s Medicare beneficiaries are eligible for the coverage due to their age (at least 65), but about 12% are under the age of 65 and eligible for Medicare because of a disability.
More than 2.25 million Texas residents are enrolled in Original Medicare (Part A, hospital coverage, and Part B, outpatient coverage), while more than 2.19 million are enrolled in private Medicare Advantage plans. The number of Medicare Advantage members has been growing faster than overall growth in Medicare enrollment.
You can read more about Medicare in Texas, including details about the state’s rule for Medigap plans, as well as the availability of optional Medicare Advantage and Medicare Part D prescription drug plans.
In 2010, Texas’s U.S. Senators John Cornyn and Kay Hutchison, Republicans, both voted no on the ACA. In the U.S. House, 20 Republican representatives from Texas voted no, while 12 Democrats voted yes. Ted Cruz has since replaced Hutchison in the Senate, and is one of the country’s most outspoken opponents of the ACA.
Former Texas Gov. Rick Perry was also staunchly opposed to the ACA and had a state legislature with a strong Republican majority. The state opted to let HHS run the exchange, has refused to expand Medicaid, and even worked to make it more difficult for navigators to do their job in Texas.
In January 2015, Greg Abbott took office as Texas’ governor. He has voiced his opposition to expanding the current Medicaid system. However, he would like to see Texas use federal Medicaid funds in the form of block grants.
Before the ACA was implemented, according to U.S. Census data, Texas had the highest uninsured rate in the country in 2013 (22.1%). It’s gone down since then, but Texas still had the highest uninsured rate in 2019, at 18.4%.
Texas leaders have been vocally opposed to the ACA, and the state has thus far refused to expand Medicaid, so a cornerstone of the law’s ability to reduce the uninsured rate is unavailable in Texas.
But more than 1.8 million Texans enrolled in private health plans through the exchange during the open enrollment period for 2022 coverage. And more than 1.7 million of them were eligible for premiums subsidies that averaged $502 per month. The subsidies are larger than they used to be, thanks to the American Rescue Plan‘s subsidy enhancements.
In addition, more than 1.1 million of the Texas exchange enrollees were receiving cost-sharing reductions in 2022, which make their out-of-pocket healthcare expenses (deductible, copays, coinsurance) less costly.
Texas only has legislative sessions in odd-numbered years. Several important healthcare reform-related bills have been enacted in Texas in recent years. They include:
- SB1296, enacted in 2021, creates an effective rate review program in the state. This means Texas no longer defers to the federal government to review rate proposals that insurers submit for the coming year. The new Texas review program is in use as of 2022, to review the rates that insurers submitted for 2023 coverage.
- SB1742, enacted in 2019, requires health plan provider directories to make it clear whether specialists practicing at in-network facilities are also in-network. In addition, the legislation imposes new rules related to prior authorization, including a readily available list of services that are subject to prior authorization requirements, and information about the insurer’s total volume of prior authorization requirements and denials.
- SB1264 protects Texans enrolled in state-regulated health plans (ie, plans that aren’t self-insured) from surprise balance billing. It applies to medical services received on or after January 1, 2020, and essentially requires the insurer and the out-of-network provider to work out the payment arrangements without involving the patient. Surprise balance billing refers to situations in which emergency care is provided at an out-of-network facility, or when a patient goes to an in-network facility but is treated — often unknowingly — by a medical provider who isn’t part of the patient’s insurance network. Instead of billing the patient for amounts above their normal cost-sharing requirements, the out-of-network provider has to use a state-regulated mediation/arbitration process to work out a payment amount with the patient’s insurer.
- SB1037, enacted in 2019, ensures that surprise balance bills that are sent to collections won’t show up on the person’s credit report.
- HB214, enacted in 2017, prohibits coverage for elective abortion on all major medical plans (including plans sold through the exchange) in Texas. Twenty-five states had already enacted similar legislation.
- SB1406, enacted in 2017, authorized the state to submit a 1332 waiver proposal to the federal government, seeking permission to waive the actuarial value requirements that currently apply in the small group health insurance market. The idea is to allow small group plans to have a wider range of actuarial values, instead of having to conform to the current bronze, silver, gold, or platinum categories. The legislation was signed into law in May 2017, but the state never submitted a 1332 waiver proposal. The Texas Department of Insurance published a brief in early 2018 detailing several other potential 1332 waiver proposals that could be used to stabilize the individual market, but related legislation was not enacted in 2019.